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Download Child Information Form WELCOME To assist us in providing the
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Child Information Form Chart # _________________ WELCOME To assist us in providing the most complete service, please provide the following information and health history. Date ____________________ PERSONAL INFORMATION Name ______________________________________________________________ Nickname _________________________________ First Middle Last Sex _________ Age ________ Date of birth _____________ Mo. Day School _________________________________ Grade ____________ Yr. Brothers/Sisters (Name and Age) __________________________________________________________________________________ Dentist _____________________________________________ Physician _______________________________________________ Referred by __________________________________________________________________________________________________ MOTHER FATHER Name ________________________________________________ Name ________________________________________________ Address ______________________________________________ Address ______________________________________________ ______________________________________________ (If different) ______________________________________________ Home phone ___________________________________________ Home phone ___________________________________________ Mobile phone __________________________________________ Mobile phone __________________________________________ Employed by __________________________________________ Employed by __________________________________________ Work phone __________________________________________ Work phone __________________________________________ Birthdate: ____/____/____ SS#: ______________ Birthdate: ____/____/____ SS#: ______________ Marital Status ________________________________________ Marital Status ________________________________________ Parent’s email address ___________________________________ Parent’s email address ___________________________________ Person Responsible For Account ____________________________________________________________________________________ PRIMARY DENTAL INSURANCE ONLY Ortho coverage? Yes No If “Yes” complete below SECONDARY DENTAL INSURANCE ONLY Ortho coverage? Yes No Insurance Co. Name: _____________________________________ Insurance Co. Name: _____________________________________ Insurance Co. Address: ___________________________________ Insurance Co. Address: ___________________________________ Insurance Co. Phone #: (_____)_____________________________ Insurance Co. Phone #: (_____)_____________________________ Group # (Plan, Local, or Policy #): ___________________________ Group # (Plan, Local, or Policy #): ___________________________ Policy Owner’s Name: ____________________________________ Policy Owner’s Name: ____________________________________ Relationship to Patient: __________________________________ Relationship to Patient: __________________________________ Policy Owner’s Birthdate: ____/____/____ SS#: ______________ Policy Owner’s Birthdate: ____/____/____ SS#: _______________ Policy Owner’s Employer: _________________________________ Policy Owner’s Employer: _________________________________ FOR OFFICE USE ONLY Insurance Verification Lifetime Max ___________ How much Met? ___________ Claim Address: ______________________ Date: ____________________ How to bill: Mos ____ Qtr. ____ 6 mos ____ Annual ____ __________________________________ Effect Date: ______________ Payer I.D. _____________________________________ __________________________________ Ded.: ____________________ Carrier # _____________________________________ DAVID C. HAMILTON, JR., DDS, MS, PA 322 10th Ave. Drive NE Hickory, NC 28601 Member American Association of Orthodontists Diplomate American Board of Orthodontics Phone 828.324.4535 • Fax 828.324.8748 Website: www.hickorysmile.com PLEASE COMPLETE OTHER SIDE MEDICAL HISTORY DENTAL HISTORY Please check box if patient has or has had: Positive HIV test Tuberculosis Joint swelling Anemia Bone disorders Asthma Heart trouble Epilepsy Rheumatic fever Prolonged bleeding Thyroid problems Faintness/Dizziness Diabetes Tonsils removed Hepatitis Adenoids removed Emotional problems Sore throats Brain injury Tonsillitis Kidney or liver involvement Earaches Please check box if answer is yes: Any injuries to face, mouth, teeth? (circle) Thumb, finger, lip sucking? (circle) Mouthbreathing when asleep, awake? (circle) More than average amount of decay? Any missing permanent teeth? Any extra permanent teeth? Any teeth removed by extraction? Is there any tongue-thrusting problem? Any speech problems? Any difficulty in swallowing or chewing? Any pain or clicking on opening mouth? List any other serious illnesses: ______________________________________________________ Is patient adopted? At what age? ______________________ List any allergies: ______________________________________ Does patient visit dentist regularly? List drugs or medications now being taken: ____________________________________________________ Has an orthodontist been consulted previously? Do you smoke or use tobacco products? Yes No Is patient under physician’s care presently? ___________________ Reason: _____________________________________________ Date of last dental visit ______________________________ Reason: __________________________________________ List any wind instrument played: ____________________________________________________ Sports: _____________________ Hobbies: __________________ Name of physician: _____________________________________ Other family members treated: ____________________________ Approximately how much has patient grown in the last year? _________ Additional comments: ____________________________________________________________________________________________ GIRLS ONLY Has the patient started her monthly periods? Yes No DK/U Is the patient pregnant? Yes No DK/U If so, approximately when? ______________________________ Please note any other factors the doctor should know about the patient’s dental health: _____________________________________________________________________________________________________________ What are your chief concerns regarding your child’s orthodontic condition? (Overbite, crowding, etc.) _____________________________________________________________________________________________________________ Please describe your reasons for considering orthodontic treatment. Please describe your child’s attitude toward orthodontic treatment. Improved facial appearance Wants it done Improved functional health Does not want it done Enhanced long-term dental health Does not care Other ____________________ PATIENT AUTHORIZATION - PLEASE SIGN BELOW I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services. X_________________________________________________ Signature of parent or guardian Date I authorize the dental staff to perform the necessary dental services my child may need. X_________________________________________________ Signature of parent or guardian Date If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. X_________________________________________________ Signature of parent or guardian The Parent or Guardian who accompanies the child is responsible for payment. Date Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
